The colonial present in international development? The case of German interventions in obstetric care in Tanzania

Introduction

When I began my research in 2008, I was surprised to find the following statement on the website of the Tanzanian German Programme to Support Health (TGPSH), the most significant German development programme on health in Africa: ‘German Tanzanian Cooperation in Health can be followed back to the 19th century’ (TGPSH, 2008). This allusion to the colonial period is astonishing given the general denial of colonial legacies in international development. TGPSH realigned with this tendency when relaunching its website recently: all references to the colonial history connecting Germany and Tanzania have disappeared.

Challenging the notion of a clear break between colonial-era interventions and post-WWII development, postcolonial approaches have urged us ‘to unnaturalize stories of development’ (Power, 2006: 28). In addition to general deliberations on how postcolonial theory can be fruitfully applied to Development Studies (Kapoor, 2008; McEwan, 2009), scholars have explored the continuation of colonialera relationships between donor and recipient countries (Biccum, 2005; Slater and Bell, 2002), the impact of racialization (Kothari, 2006), the intertwining of gender and ‘race’ (White, 2006) and subjectivities of development workers (Heron, 2007). Drawing on their insights, the assumption of this article is that colonialism affects contemporary development. It takes this assumption to the field of German policy and practice regarding obstetric care in East Africa, and undertakes an empirical investigation of German interventions. This article suggests that present-day interventions to a certain extent do echo hierarchies between German and East African practices articulated during colonial rule. However, it cautions against understanding contemporary interventions as ‘colonial’ only because of discursive similarities. Instead, it attempts to discern the ‘colonial’ in both periods, and—through attention to similarities and differences—reflects on whether contemporary GDC with Tanzania can be considered colonial. This article argues that German obstetric care interventions in Tanzania today evidence colonial power because of a combination of racialization, developmentalism and trusteeship, but these interventions are also marked by hesitancy of German professionals and declarations of failure to induce change.

It is a timely undertaking as the German case is under-researched even though Germany is one of the world’s biggest ‘donor’ countries. Previous postcolonial development research has mainly focused on activities by British (Biccum, 2005; Noxolo, 2006; Slater and Bell, 2002) and to a lesser degree Canadian (Heron, 2007) and Scandinavian (Eriksson Baaz, 2005) agencies, institutions and professionals. Studies that take a postcolonial perspective on German development aid have focused on general policy orientations (Deuser, 2010; Kontzi, 2015), which this article complements by zooming in on actual policy implementation. GDC is particularly apt for such an analysis as it—in contrast to other ‘donors’—favours a multi-level approach that also entails the deployment of actual practitioners on the ground. The issue of childbirthrelated practices lends itself to an analysis as it was a prime target of colonial policies for transforming the colonized people in the name of civilization and modernity (Ram and Jolly, 1998; Vaughan, 1991). Focusing on Tanzania as a particular case of GDC is suitable as it previously formed part of Germany’s largest colony ‘German East Africa’. German interest in the realm of childbirth in GEA was sparked by a colonial ‘reformist’ agenda after the turn of the 20th century and entrenched in concerns of a ‘population decline’ (Colwell, 2001). Present-day Tanzania is a focus country of GDC, and maternal health is amongst GDC’s priority areas in Tanzania. Given Germany’s concern with birthing in East Africa in the colonial past and today, this case provides a unique lens through which to explore whether colonial power is alive in contemporary development.

Despite ample criticism, there appears to be much faith in development cooperation. Thus, Development Studies focuses on practical interventions and is largely future-oriented (Kothari, 2011). Recently, however, scholars have shown increasing interest in the history of development (Bayly et al., 2011; Woolcock et al., 2011). Woolcock et al. (2011) regard history as a resource for self-reflection: Why are certain issues focused on and not others, and why have interventions come to take their particular form in the present? While existing historical approaches in Development Studies tend to focus on the evolution of institutions and economic development (Bayly et al., 2011; van de Walle, 2009), this article provides evidence that rereading discourses and practices of contemporary development cooperation through a comparison with colonial times gives substance and sophistication to the postcolonial claim that particular ‘racial formations constructed through colonial processes are re-presented and re-articulated’ in international development (Kothari, 1996: 3). A thorough understanding of the influence of colonialism on contemporary issues of development provides the necessary ground for imagining a ‘de-colonized, de-whitened, post-colonial’ development cooperation (Crush, 1994: 334).

The present study builds upon approaches which examine colonial-era policies and link them to contemporary endeavours (Deuser, 2010; Noxolo, 2006; Wainwright, 2008). So far, postcolonial development research has largely refrained from analyzing specific interventions and primarily focused on general policy orientations (Biccum, 2005; Noxolo, 2006; Slater and Bell, 2002). By undertaking a concrete scrutiny of maternal health policy and practice as presented by German professionals and by rereading present interventions through the lens of the colonial past, this article offers an assessment of colonial power in present-day development that does not remain abstract. Rather than criticizing development for generally disregarding its legacy, it highlights how that legacy plays out in the promotion of specific manners of thinking, practices and work ethics.

This article draws on scientific and government publications, archival sources of the German colonial administration and documents of GDC. Between 2009 and 2011, I also conducted semi-structured interviews with 59 mainly German professionals in Germany and Tanzania involved in reproductive health in Tanzania (for a list of cited interviewees, see Appendix). My positionality as a ‘white’ German with experience in GDC and settings such as being hosted in development professionals’ private homes helped to create an atmosphere in which my respondents seemed comfortable enough to share uncertainties regarding their work. I should stress here that this article focuses on German perspectives of development cooperation, and does not account for the perspectives of Tanzanians.

Since the aim of this study is to examine the connections between contemporary development and the colonial past, it is part of postcolonial studies with their interest in ‘the persistence of colonial forms of power and knowledge into the present’ (Kothari, 2011: 69). Drawing on postcolonial theory, ‘colonial power’ is chosen as a concept to characterize the kinds of power that emerged during European colonialism and are still operative in the present (cf. Gutiérrez Rodríguez, 2010; Mbembe, 2001; Quijano, 2000). By not reserving the notion of colonial power to refer to the period of actual territorial occupation, the difference between the period of formal colonial rule and the post-colonial era can be examined ‘as the reconfiguration of a field, rather than as movement of linear transcendence between two mutually exclusive states’ (Hall, 1996: 254). Power here is conceived as discourses, that is, dominant ways of thinking, and their interconnectedness with the material world (Foucault, 1980). Discourse analysis is particularly suitable for historicizing the present as discourses refer to the level of knowledge that cannot be attributed to individual actors, although they take effect in the world through actors (Isaac, 1992). Their agency has stabilizing or transformative effects on power (Scott, 1990).

This article consists of three parts. In each part I first review contemporary GDC, then turn to the colonial period, and conclude by comparing the two periods in order to shed new light on the present. The first part analyzes the manner in which childbirth-related practices in GEA were generally perceived by German professionals and institutions and the interventions proposed today and during colonization. The second part addresses health care planning and management. The third part explores the manner in which German commentators in both periods have raised the issue of attitudes in obstetric care.

Ambivalent hospitals

Tanzania’s maternal mortality rate was 460 in 2010, which puts Tanzania in 23rd place worldwide (CIA World Factbook, 2014). Maternal deaths account for 17 per cent of all deaths of women between age 15 and 49 (National Bureau of Statistics and ICF Macro, 2010). Provision of reproductive health care for women is generally marked by poor, unaffordable treatment at health care facilities, where staff are underpaid and must pursue additional income-generating activities (Allen, 2002). Only about half of births take place in health facilities and are assisted by ‘health professionals’ (National Bureau of Statistics and ICF Macro, 2010). The remaining home deliveries are assisted by ‘[t]rained and traditional birth attendants’ and ‘relatives or other untrained people’ (ibid.: 135–36).

Contemporary German development aid finds obstetric care in Tanzania to be lacking and commonly relates this to restricted ‘access to skilled birth attendants and to good obstetric care’ (BMZ, 2008: 9). Germany and other international donors have until recently supported the training of ‘traditional birth attendants’ (TBAs) in biomedical health care but the desired effect of lowering maternal mortality has not materialized. As a consequence, maternal health policy today generally does not include TBAs. In Tanzania, ongoing GDC links high maternal mortality and poor maternal health to a high prevalence of home births, especially among poor women (I14). German development professionals regard giving birth to be risky because TBAs, who often assist home births, are perceived as unskilled and relying on ‘experiential’ or ‘traditional’ (I02, I08, I10 and I28) rather than on ‘Western-based, evidence-based medicine’ (I08). The stated aim of German development aid is to have all deliveries performed in biomedical health facilities.

At the same time, GDC points out the insufficient quality of obstetric care in those facilities. Their deficiencies are highlighted as one of the reasons why Tanzanian women avoid official health facilities. In the interviews with German professionals, Tanzanian hospital staff were characterized as lacking know-how and capacity. A German doctor working in a large Tanzanian hospital explains how she perceives nurses’ deficiencies:

[…] there are some, that’s a catastrophe, a real catastrophe. […] That might have to do with their training. You can pose any question from the schoolbook. And you get a whole page rattled out by heart. But in a concrete situation … no consequence whatsoever, […]. (I35)

This professional regards nurses as unaware of the fundamentals of obstetric care. According to several German physicians and nurses I interviewed, Tanzanian hospital nurses were unable to implement their acquired knowledge in practice, and were merely capable of mechanically reproducing what they had learned by heart. Some German professionals conceded that they considered some nurses and doctors to be highly skilled, if they followed practice familiar to them. One interviewee said that she had ‘fantastic colleagues, really, who think, act and plan exactly as I am used to from back home’ (I29). This remark evidences that standards associated with German hospitals are conceived as desirable but are met by only a few. With regard to a specific childbirth-related practice, several German physicians and nurses complained about the almost exclusive use of the supine birth position in Tanzanian health facilities. They considered it a highly unsuitable birthing position, ‘right after a handstand’ (I29). They added that it was a way of exerting authority over the women giving birth and said that they tried to introduce other birthing positions.

‘Giving birth in the white people’s manner’

Having explored German perceptions of, and interventions into, obstetric care today, I now examine German childbirth-related practices during colonialism. Just like their European colleagues in other colonial contexts, German physicians, missionaries and administrators after the turn of the 20th century proceeded to assess the childbirth-related practices they encountered in GEA. Some were deemed functional, others inappropriate. Commentaries such as the following by a senior staff surgeon in Kilwa give evidence of such estimations of East African midwifery:

In cases of lateral or posterior positions, a correction is undertaken through hand pressure and massage; one also drinks a medicine in such cases. […] In case of premature bleeding during pregnancy, one also applies dawa—medicine—internally, bed rest is also prescribed; in serious cases […], the mother dies inevitably due to exsanguination, since they do not know internal interventions. (Peiper, 1910: 461–62)

This German doctor acknowledged certain practices as useful, while maintaining that the East African midwives were unable to deal with serious complications. Most of all, however, German commentators accentuated perceived deficiencies (Feldmann, 1923; Ittameier, 1923; Reichs-Kolonialamt, 1913). Evaluations at times amounted to positing a complete ‘lack of pregnancy and maternity protection’ (Peiper, 1920: 19).

Yet German colonizers did not always speak with one voice. For example, a mission superintendent considered midwifery among East Africans fairly developed (Axenfeld, 1913), and the Medical Reports of the German Administration explained the limited use of German hospitals for childbirth as partly due to the fact ‘that the native midwife is quite skilled’ (Reichs-Kolonialamt, 1915: 233). A staff surgeon in Dar es Salaam even mentioned that in some ‘tribes [….] quite a number of really useful midwives exist, who stand out in skilfulness and a certain empirically acquired expertise, so that they were even asked to carry out deliveries of European women in some especially favourable cases’ (Feldmann, 1923: 129).

In order to transform obstetric care, the German colonial stakeholders implemented numerous interventions: increasing the number of German medical doctors and midwives, training East Africans in nursing and midwifery, building health facilities, and propagating Christianity in order to root out the influence of ‘pagan mothers-in-law’ (Feldmann, 1923: 142). The German Society for the Protection of the Natives (1914) was convinced that lack of ‘delivery institutions for natives’ was responsible for a poor obstetric situation and the German Women’s Association for Nursing in the Colonies (1909) pressed for the inauguration of ‘institutions for the education of native midwives, nurses, and nurse aides as well as the founding of delivery homes for natives’.

More government physicians and medical officers were deployed, mission societies sent midwives, leaflets with behavioural advice for pregnant women were distributed and the training of ‘adequate native women as midwives’ started just prior to the demise of German colonial occupation (Feldmann, 1923). As an example of concrete interventions into birthing, the issue of delivery positions is noteworthy. A colonial-era report from a German medical doctor mentions that ‘the seating of the woman in labour in a supine position on a clean […] sheet was made obligatory’ (Rodenwaldt, 1912: 275). This specific type of birthing on a stretcher in the supine position was the widely accepted practice in Germany at the time (Dziedzic and Renköwitz, 1999). According to German reports, East African women often preferred other positions (Axenfeld, 1913; Peiper, 1910). In some areas of Tanzania, to give birth in this position is still today referred to as ‘giving birth in the white people’s manner’.

Relating the present to the past

During formal colonial rule, the colonizers attempted to replace ‘traditional’ East African midwifery with ‘modern’ European biomedical practices (Langwick, 2011). German practitioners today no longer establish difference by opposing ‘modern’ biomedicine to ‘traditional’ practices. Instead, they differentiate full-fledged biomedical obstetric care as practiced in Germany from its deficient adaptation or the maintenance of outdated biomedical practices in Tanzania. Yet in contemporary GDC, biomedically trained Tanzanian health personnel are depicted in a similar manner as were ‘native midwives’ during colonization: lacking skills and knowledge. Thus, despite the hegemony of biomedical health care in Tanzania today, the ‘dichotomizing system’ (Mudimbe, 1988: 4) introduced by Germans during colonization between correct German obstetric care and deficient Tanzanian practices is rearticulated. In both periods, obstetric care is measured against German midwifery, and differences are considered deficiencies. Rearticulating the assumption of linear progress of obstetric care with German standards as the epitome of ‘development’ (despite the obvious non-linearity of changes in ‘truth’ as evident in the case of birth positions) can be considered colonial in contemporary German interventions today (cf. Dussel, 1995).

Notwithstanding the general devaluation of East African obstetric practices during colonialism, German professionals partially acknowledged East African practitioners’ knowledge and skills. This might be explainable by the fact that obstetrics in Germany had not yet fully entered the sphere of the hospital and the all-male medical profession; home births with the help of female practitioners were still the norm at the time (Major, 2003). Moreover, there was no significant medical advantage of a German physician assisting deliveries through ‘Caesarean sections […] in the pre-antibiotics era in the tropics’ (Colwell, 2001: 101). Given that maternal mortality was significant in imperial Germany (Bundesinstitut für Bevölkerungsforschung, 2014), a sense of superiority must have been harder to uphold. Today, German obstetric care fares so much better statistically, with a maternal mortality rate 66 times lower than in Tanzania (CIA World Factbook, 2014), which explains GDC’s assumption of superiority.

It is striking that commentators in both periods never mentioned the knowledge, skills or functions of East African midwives that were less reconcilable with German biomedicine, such as use of herbs, charms, spiritual powers and communication with ‘nonhumans’ (cf. Langwick, 2011). Today, German professionals also do not take into account that nurses and nurse aides in Tanzanian health facilities often mediate between ‘modern’ biomedical and ‘traditional’ healing (Langwick, 2011). They also tend to disregard the fact that TBAs often occupy a much broader societal role than merely assisting with birthing (World Health Organization, 2005). The colonial-era devaluation of ‘non-professional’ female knowledge and practice is thus echoed in contemporary GDC, and the disregard for East African alternative knowledge and practice evidences a colonial legacy in contemporary GDC (cf. Briggs and Sharp, 2004).

Implanting a ‘planning culture’

In my interviews, German development professionals often claimed that the poor state of obstetric care in Tanzania was caused by Tanzanian professionals’ deficient sense of planning, forethought and management skills. Governmental administration and management in Tanzania were considered chaotic, bureaucratic and slow (e.g., Interviews I18, I19 and I20). This assessment was extended to several areas of hospital management: budgeting, organization, drug procurement, storage, equipment maintenance and so on. According to a former senior manager of the German health programme, GDC in Tanzania was consequentially about creating a ‘planning culture’ (I10). The view of a Tanzanian who used to work as a hospital manager and for GDC sheds a different light on the matter. He said that many German professionals would almost instantly begin by telling Tanzanian colleagues what they did wrong and what they should change (I52). According to this Tanzanian professional, ‘development workers’ should learn to support existing structures and habits of working: ‘You cannot turn our health system into a German health system; you cannot change our management system and want a completely new one.’ He suggested that ‘development workers’ needed to be instructed prior to their deployment that they were neither going to the ‘jungle’ nor to work with people that did not know anything.

The perception that Tanzanian practitioners could not plan well or think independently was particularly evident in the way German professionals talked about the Tanzanians’ inappropriate use of the partograph, a tool for monitoring progress of delivery. Many of the German health workers reported that Tanzanian nurses commonly did not fill it in at all or did so incorrectly, or that nurses did not take the appropriate actions on the basis of a filled-in partograph. A professional specialized in obstetrics, who worked in a Tanzanian district hospital, reports GDC’s experiences in propagating use of the partograph:

And this lady [his German development aid colleague] was training this partograph for five years now, and still, every time she went to the hospitals, the same people did not understand the partograph (I08).

Thus, the inability of Tanzanian hospital staff to use the partograph properly despite repeated training is met with disbelief by this development professional. In another interview, a German nurse working in a hospital as well as a training centre for midwifery in Tanzania tried to make sense of the problems she saw in obstetric care in general and in the use of the partograph in particular:

Well, I slowly try to figure out what actually is the problem. I believe that the problem is partly that documentation is tedious, you know. […] There is somehow no sense of priorities whatsoever. […] I may be able to teach it to them and we have gone through the partograph five times, and now during the exam, I see […]: they still don’t know it. […] This way of systematic association, it’s missing somehow. (I29)

The interviewee shows some understanding of the deficiencies in organization when she refers to the workload. However, aside from these structural factors, she mentions that nurses write long narratives instead of concise information. She notes an inability of her student nurses to think systematically and to connect theory to actual practice, without reflecting on her own inability to comprehend her students’ behaviour and her own deficient teaching competence.

While being aware of the ‘political incorrectness’ of her statement, her overall diagnosis is that Tanzanians (or even more broadly, ‘Africans’) naturally do not have the capacity to think, plan ahead, anticipate and consider options:

[…] that sounds really racist now perhaps what I’m saying, sorry, but, I believe, it has to do with a lacking, well, to do with time, and a …. not … prospective … ehm, prospective thinking, you know, well, the way we and I mean, I believe, this debate has always existed, how, well, Africans, sense of time, there are also ethnological studies regarding this somehow, that you, that they don’t plan, yes. […] And, I believe, we are like that, that we do not only think of one way […] And well, I have the feeling here that they are always surprised … you understand, of course all children get born somehow, yes. But .. they .. do not think .. ahead. (I29)

It must be noted that such statements were probably voiced so openly due to my position as a white European. The German nurse considered me part of the ‘we’ as opposed to the ‘they’. She tried to understand her nursing students’ behaviour through the racialized categories of ‘Africans’ (‘they’) and ‘Europeans’ (‘we’). Tanzanians were perceived as living in the present only which made them fundamentally incompatible with the biomedical health model that required abstract thinking and anticipation of possible outcomes. Other interviewees also assumed that Tanzanians somehow naturally did things differently and had a different sense of planning (e.g., I30) and that ‘Tanzanians cannot think logically’ (I32). Tanzanians appear as a homogeneous group incapable of systematic thinking.

The above-mentioned interviewee I08 also asked himself what to do in the face of the reluctance by Tanzanian professionals to use the partograph:

Is this because this is our system, our idea? This is Western-based medicine, this is evidence-based medicine, but it doesn’t work somehow. So we sometimes say, yeah, if it doesn’t work, why try to continue with it, why try to … teach and implement this thing, […]. Who are we, who are we as white doctors to say, this is the best one? (I08)

This doctor raised the point of possible incompatibilities of Western and Tanzanian medical paradigms. He considered giving up the transfer of health knowledge to Tanzanian hospitals, but did not consider alternative paradigms or ways of teaching health care. In the follow up to the excerpt above, the same interviewee brushed off his uncertainty by pointing out that if he began to doubt his ability to bring about positive change, he would have to question the whole project of international development cooperation, and quite literally ‘go home’.

Installing a health care system for East Africans

In publications and reports from the colonial era, there is little mention of planning by East Africans in obstetrics or, more generally, health care. This silence regarding East Africans’ capacity to plan their lives is revealing, as it can be understood as grounded in the assumption that Africans are people without history and incapable of building a future (cf. Kebede, 2004). German commentators sometimes explicitly stated that they thought Africans were unable to organize their lives. A staff surgeon mentioned East Africans’ ‘hand-to-mouth life’ and ‘lack of foresighted planning’, which would make it difficult for them to endure the fight for survival (Feldmann, 1923: 139). The construct of East Africans as passive and unambitious allowed the German colonizing endeavour to assume trusteeship: to ‘educate’ East Africans to become good Christians, good workers and proper housewives; and to guide them in health matters (Koponen, 1994).

Consequently, the role attributed to colonial health professionals was to employ ‘theoretical and applied science’ (Dernburg, 1907: 9) to take care of East Africans. Planning and management were fundamental to Germany’s colonial endeavours. German doctors, nurses, missionaries and administrators meticulously established statistics, planned intervention, discussed infrastructure and financing and reported on cases of sickness in a detailed manner (e.g., Medizinalreferat in Daressalam, 1914). The colonial administration undertook a flurry of demographic and health surveys (Colwell, 2001). Medical population planning was deemed essential for the growth of the African population.

Relating the present to the past

Today, German professionals do not necessarily take the task of planning and management into their own hands, but attempt to teach Tanzanians what they consider proper planning. While devaluing the others’ knowledge and skills cannot per se be considered colonial, the tendency to relate perceived planning deficits to Tanzanian learning ability or Tanzanian/African ‘culture’ is racist in that it binds specific (inferior) traits to people grouped together on the basis of origin (Memmi, 2000). It relies on the assumption that Africa’s capacity for ‘progress’ and ‘development’ is minimal. Perceived deficiencies are at times also explained by structural factors, such as socio-economic conditions and educational systems. Even then, the German professionals I interviewed tended to propose universal solutions and stuck to the aim of changing the ‘planning culture’ so that Tanzanian obstetric care would one day resemble that of the global North. It was portrayed as unable to function properly without trusteeship of German development (cf. Cowen and Shenton, 1996). Other approaches, as proposed by the Tanzanian hospital manager cited, seemed unperceivable.

At the same time, some German professionals doubted their own usefulness and legitimacy. The Tanzanian health workers’ seemingly inexplicable immunity to reform profoundly unsettled their confidence to effect change. Colonial discourses and practices of trusteeship seemed to be undermined. Despite such doubts, German professionals did not seriously question their superior knowledge, the superiority of Western medicine and health care and the need for development intervention (hardly surprising given the stark difference in maternal and child mortality between Germany and Tanzania). In her study on former Canadian aid workers, Heron points out that the work of development professionals is ‘contingent on positioning the Southern Other as available to be changed, saved, improved, and so on, by us, thereby ensuring our entitlement to do so’ (2007: 44). However, at the same time colonial discourse tends to operate on the thesis that ‘African culture is not susceptible to change’ (Heron, 2007: 45). In the case of the policy field under scrutiny here, when intervention fails Tanzanian society (whether because of structural reasons or the ‘nature’ of Tanzanians) is held accountable for the failure of German professionals to induce change.

Post-modern birthing

In contemporary GDC, professionals also referred to Tanzanians’ mindsets and attitudes in order to assess health care around childbirth. Here, two important issues emerged: motivation and compassion. In the following excerpt, a German physician working in a Tanzanian hospital speaks of the way pregnant women are treated by Tanzanian nurses in the hospital in which she is deployed:

[…] you just have the feeling that every patient who enters is perceived as a source of irritation, who interrupts the nurses drinking tea. […] If you come from outside and, moreover, you have a European head on your shoulders, you find some things really horrible. […] They let the people give birth on a wooden board in the toilet. And next door there are two wonderful delivery beds, but these wonderful delivery beds are reserved for when somebody from the family or the staff comes. (I35)

In my interviews, several German development professionals characterized nurses, and also doctors and the political elites working in the health field, as indifferent, ‘apathetic’, ‘unmotivated’, ‘idle’ and ‘not enthusiastic’ (I29, I37, I28, I54 and I53). For example, according to a German doctor in a Tanzanian district hospital, nurses did not find it problematic to be ignorant, and refused to criticize colleagues for wrongdoings (I37). During training workshops they would allegedly reproduce inert knowledge, that is, present mechanically what they had read or heard without thinking. She attributed what she perceived as indifferent attitudes to a general lack of public scrutiny of civil servants in Tanzania, to a ‘culture’ of not thinking independently and voicing criticism and to an intrinsic indifference.

Another aspect invoked in the quote above is the apparent lack of compassion of Tanzanian health workers. Several interviewees complained of the absence of empathy for pregnant women and mothers. Tanzanian nurses allegedly did not care about the psychological or emotional well-being of their patients, and sometimes even resorted to verbal as well as physical violence in order to assert their authority. Here, German health professionals saw it as their task to convey compassionate midwifery, which according to them meant looking patients in the eye, massaging expectant mothers and generally taking the needs of patients seriously. Midwifery in Tanzania was perceived as highly ‘programmed’ and not very ‘interpersonal’ (I15). This interviewee compared such attitude to practices in Germany 30 years prior, and criticized it as too ‘modern’ in the sense of too mechanistic and not sufficiently sensitive. Here, ‘modernity’ ironically means backwardness. She contrasted this to the current state of the art in Germany, where midwives had ‘become a little bit more generous’ and regarded giving birth as something ‘individual’. German professionals reported that the supine position was favoured in Tanzania because it allowed practitioners to exert maximum control over birth processes and women in labour. They claimed that Tanzanian nurses or doctors would not consider squatting down because it would question the hierarchy between patients and staff. Here, Tanzanian hospital staff is construed as authoritarian and insensitive. For the German health workers I interviewed, professionalism apparently includes empathy and compassion. They perceive themselves not only as enhancing Tanzanian health workers’ technical skills, but also as improving the interpersonal level of health care. Crude mechanical Tanzanian midwifery is thus differentiated from caring, sensitive, post-modern German midwifery providing the ‘clients’ with room to express their individuality freely (cf. Ahrendt, 2012).

The ‘bitter struggle between darkness and light’

The archival material evidences that particular attitudes were considered crucial for quality obstetric care in the colonial past as well. Three issues were highlighted by German commentators with regard to East Africans’ attitude towards health matters: timidity, superstition and carelessness. These aspects were continually mentioned by administrators, physicians and missionaries to explain the supposedly poor health situation of mothers and their children in GEA. First, they held that women’s ‘suspicion and timidity’ (Ittameier, 1923: 56) made them fail to consult German health practitioners; they would only do so in the ‘most dire’ circumstances (ibid.: 50). Influence of elderly women and the persistence of ‘customs’ of giving birth at home served as explanations for non-attendance (Gouverneur von Deutsch-Ostafrika, 1909). German missionaries put a lot of effort into drawing East African women to their facilities (Walter, 1992) and were probably aware that ‘African “midwives” […] exercised a large degree of social and moral control which had to be broken if Christianity was to succeed’ (Vaughan, 1991: 66).

German commentators furthermore explained poor obstetric health conditions for East African women by pointing to their alleged superstition and indifference. The following quote by a staff surgeon is an example of such a position. He argued that a transformation of people’s ‘psyche’ through schooling and mission was necessary:

[…] superstitious beliefs can be pushed back through such an instruction, their effectiveness can be eliminated, and a certain degree of positive knowledge in child care and care of the sick can be conveyed through schools. […] Since the basis of the pagan treatment of the ill—animism, dread of ghosts and raw selfishness—relies on fear, a sensible care of the ill and of children can only be achieved by the destruction of that basis and new directions for the psyche of the natives. […] It is basically a bitter struggle between the darkness of the pagan being and the light of Christian insight and charity whose instrument is the mission. (Feldmann, 1923: 140–42)

Superstition, as well as selfishness, were seen as defining characteristics of East African health care. German professionals held people’s belief in ‘spirits and magic’ accountable for inadequate responses to diseases (Ittameier, 1923: 54). Women in particular—‘pagan mothers, grandmothers, mothers-in-law as well as sorcerers’ (Feldmann, 1923: 140–42)—were suspected of disseminating superstitious beliefs, much as the ‘wise women’ and their knowledge and influence had been deemed dangerous in Europe before.

Colonial commentators did not only deplore ‘superstitious beliefs’, they also accused the colonized people of carelessness, irresponsibility and indifference regarding health care and childbirth-related care in particular. East Africans were said to be inaccessible to advice and training (Feldmann, 1923) and indifferent to proper infant care (Reichs-Kolonialamt, 1913). Portraying mothers as careless was not specific to German colonization of East Africa but common in many contexts in which colonizers were concerned about population decline after the turn of the 20th century (Ram and Jolly, 1998).

Relating the present to the past

In ongoing development cooperation as well as during German colonial rule, matters of attitude served to construct difference and hierarchy between German and East African obstetric care. In the characterization of Tanzanian health practices in current German development aid, superstition does not play an important role. Instead, Tanzanian professionals are described as unmotivated, rude and lacking compassion. There is some common ground here, however: Germans in both periods constructed East Africans as inactive, relating their inactivity to backwardness (cf. Mbembe, 2001). Today, however, structural factors are sometimes also invoked as explanations for problems in health care. As mentioned before, this cannot be considered colonial thinking. Yet, Tanzanians’ attitude is also related to a specific ‘culture’ of indifference and carelessness and thereby racialized.

Comparing contemporary with German colonial-era intervention indicates an interesting shift. In colonial times, Tanzanian health care was perceived as not modern enough and insufficiently medicalized, a view that can be explained by the fact that state bodies and doctors in Germany tried to regulate and medicalize midwifery as much as possible at the turn of the 20th century (Szász et al., 2012). Today, midwifery in Tanzania is regarded as too regulated and lacking in compassion. Since the 1980s, medicalization of birthing has been increasingly criticized in Germany, and home births and ‘family-oriented midwifery’ have become popular again (ibid.). Given that medical knowledge and practice constantly advance, the shifting German notions of quality obstetric care are not surprising. Yet to establish one’s own knowledge—regardless of its provisionality—as universal norm and to project it onto the lives of people in the global South, without being interested in or capable of interacting with the others bears traces of colonial power (cf. Dussel, 1995).

Conclusions

The focus on the policy field of obstetric care and its implementation in the specific context of German–East African relations has allowed for a detailed understanding of whether the colonial legacy affects contemporary development cooperation. It became evident that German professionals continue to establish a fundamental hierarchy between themselves and East Africans in their assessment of Tanzanian childbirth-related practices. However, the ways in which German professionals make sense of Tanzanian midwifery are complex. If perceived deficiencies are explained with reference to social factors such as education or lack of public scrutiny, this cannot be considered colonial. That is the case, however, when estimations are based on racialized thinking, which is the case when professionals relate perceived deficiencies to notions of an intrinsic Tanzanian character, ‘culture’, or even ‘Africanness’ (cf. Kothari, 2006). From the perspective of German professionals in the past and today, childbirth-related practices in East Africa have always lagged behind, and East African alternative knowledge and practice is disregarded. German interventions into childbirth-related attitudes throughout are justified with reference to Germany’s construct of itself as epitome of progress. Accordingly, what Germans considered to be the norm was projected onto East Africa (cf. Mignolo, 2002): masculinized professionalism, rationality and Christianity during colonialism, and rational planning, empathy and sensitivity in the present. In addition to positing teleological developmentalism, German professionals have thus always regarded themselves as having to guide East Africans towards German standards of birthing. This shows that the practice of trusteeship—imposing Western epistemology and modes of organization—on the global South is ever-present (cf. Cowen and Shenton, 1996).

Despite the observation that contemporary GDC on obstetric care in Tanzania tends to re-articulate racialization, developmentalism and trusteeship, interventions today are marked by considerable hesitancy and realization of ineffectiveness. Frustrated by the lack of success, some development professionals had to make an effort to keep up their self-image as able to mould the world (cf. Dyer, 1997). The manner in which they dealt with their frustrations substantiates the finding that ‘representations in the development aid context are characterized by hesitancy and a degree of self-reappraisal over time, which co-exist […] with the location of the problem in Africa and the solution in the West’ (Eriksson Baaz, 2005: 164). While uncertain about the value of their work and approaches, German professionals ultimately located the problem in Tanzania and could not imagine other ways of teaching midwifery.

The interviews did not yield any indication that development professionals challenged notions of Western superiority by romanticizing Tanzanians as authentic and unspoiled, as Eriksson Baaz (2005) has found. What was perceived as passivity was never presented in the form of the ‘desired passive Other’ (Eriksson Baaz, 2005: 159), but merely judged as negative and a source of frustration. Development professionals might present passivity as desirable when interviewed in a general manner about living and working in a ‘developing’ country (Eriksson Baaz, 2005; Heron, 2007), but this is not supported by this investigation of the field of obstetric care in which knowledge and skills were regarded as crucial. Here, German development professionals tended to associate passivity with stagnation and backwardness, and blamed these for poor health care. All in all, it can be said that while colonial power is alive in contemporary development cooperation in the specific case under scrutiny, the sense of entitlement to change Tanzanian practices is fractured due to practical experiences of development professionals in their day-to-day work.